Evidence Based Strategies: Winter Sports and Concussions in Pediatric Patients

Column Author: Catharine N Kral, DO| Resident PGY 3; Chief Resident

Column Author: Angela D. Etzenhouser, MD, FAAP | Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Winter sports, including hockey, wrestling, basketball, skiing and snowboarding, are high risk for head injuries. A 10-year study on pediatric skiing and snowboarding found that the most injured body part was the head.⁶ This finding is concerning given that many ski resorts do not require, but only recommend, wearing helmets. Another study concludes that the most common injury for youth ice hockey players is concussion.⁴ With winter just around the corner, high clinical concern for concussions is essential for appropriate diagnosis and management.

Diagnosing and managing sports-related concussions (SRCs) is one of the most challenging tasks in medicine due to the complex interplay of not only physical symptoms but also social, emotional and sleep-related challenges.³ An SRC is defined as a “traumatic brain injury caused by a direct blow to the head, neck, or body resulting in an impulsive force transmitted to the brain. This initiates a neurotransmitter and metabolic cascade affecting the brain.”⁵ Symptoms can include headache, dizziness, nausea, light or sound sensitivity, loss of consciousness, amnesia, poor balance, confusion, or behavioral changes.⁵ Pediatricians must be comfortable with recognizing the symptoms of a concussion and immediately removing the young athlete from activities for evaluation.

 Diagnosing concussions can be difficult. In 2004, the Sport Concussion Assessment Tool (SCAT) was developed to try to standardize clinical evaluation.³ The SCAT6 is the most recent revision of this tool, with two versions based on patient age.⁵ Initial evaluation should assess for cervical spine tenderness, include a thorough neurological exam, and include special tests such as Vestibular-Ocular Motor Screen (VOMS), Balance Error Scoring System (BESS), and several cognitive tests.⁵

Physicians should prescribe relative rest for the first 24-48 hours. Relative rest includes reducing strenuous cognitive and physical exertion but returning to activities of daily living with reduced screen time and light movement. Studies have shown that strict rest until the complete resolution of all concussion-related symptoms is not beneficial.⁵ Light physical activity, such as 20-minute walk, is recommended as long as symptoms are not exacerbated.⁵ Early return to normal activities should be encouraged as the transition back to school is an important consideration in management for these student athletes.⁵

A systematic review found that most young athletes had full return to learning (RTL) within 10 days.⁵ RTL protocols involve a team-based approach consisting of school nurses, teachers, athletic training staff, and medical providers to slowly return the student athlete to the classroom, with accommodations as needed. Pediatricians should provide school notes for modifications to help expedite the return to school. Environmental modifications include frequent breaks, paper handouts and excuses from noisy stimuli like band/choir.⁵ Curriculum modifications can include extra time on assignments and tests or preprinted notes.⁵ A history of a previous concussion, family history of migraines, mental health history including anxiety or depression, and various learning challenges such as a 504 plan, an individual education program (IEP), or attention-deficit/hyperactivity disorder have all been associated with prolonged recovery time.⁵ Once the child has been able to return to school full-time without return of symptoms, the return to play (RTP) protocol can begin.

The Return to Play (RTP) protocol is a graduated progression to safely return to full contact sport after a concussion. Each step in this five-step protocol takes at least 24 hours to complete, meaning no child should progress through more than one step per day.⁵ In the adolescent population, this protocol can often be completed in conjunction with the athletic trainer at school. For younger patients, family members can progress patients through the RTP. Pediatricians should be in close communication with the patient for evaluation and clearance before any return to contact occurs. The resolution of symptoms and return to play typically occurs within a month after the initial injury.⁵

Anticipatory guidance on how to keep winter athletes safe is essential. Wearing proper protective equipment, such as helmets and mouth guards, needs to be standard practice. A recent study found that wearing a mouth guard was associated with a 64% decreased odds ratio of sustaining a concussion in youth hockey players.⁴ Additionally, policies have progressed to help keep young athletes safe. For example, disallowing body checking in youth hockey players has reduced the rate of concussions by as much as 58%.⁵ Sports are an invaluable part of childhood. It is important for pediatricians to promote ways to keep young athletes active and safe.

References:

1. Bergmann KR, Flood A, Kreykes NS, Kharbanda AB. Concussion among youth skiers and snowboarders. Pediatr Emerg Care. 2016;32(1):9-13. doi:10.1097/PEC.0000000000000364
2. Brooks MA, Evans MD, Rivara FP. Evaluation of skiing and snowboarding injuries sustained in terrain parks versus traditional slopes. Inj Prev. 2010;16:119-122.
3. Bruce JM, Thelen J, Meeuwisse W, et al. Use of the Sport Concussion Assessment Tool 5 (SCAT5) in professional hockey, part 2: which components differentiate concussed and non-concussed players? Br J Sports Med. 2021;55:557-565.
4. Chisholm DA, Black AM, Palacios-Derflingher L, et al. Mouthguard use in youth ice hockey and the risk of concussion: nested case–control study of 315 cases. Br J Sports Med. 2020;54:866-870.
5. Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. Br J Sports Med. 2023;57:695-711.
6. Warren A, Dea M, Barron IG, Zapata I. Ski and snowboard injury patterns in the United States from 2010 to 2020 in pediatric patients. Injury. 2023;54(8):110899. doi:1016/j.injury.2023.110899